ATTESTATION FORM

WARNING : THE FURNISHING OF FALSE INFORMATION OR SUPPRESSION OF

ANY FACTUAL INFORMATION IN THE ATTESTATION FORM WOULD
BE A DISQUALIFICATION, AND IS LIKELY TO RENDER THE
CANDIDATE UNFIT FOR EMPLOYMENT UNDER THE GOVT.
2.

If detained, arrested, prosecuted, bound down, fined,

convicted, debarred, acquitted, etc. Subsequent to
the completion and submission of this form,, the
details of communicated immediately to the
authorities to whom the attestation form has been
sent earlier, falling which it will be deemed to be a
suppression of factual information.

3.

If the fact that false information has been furnished

in the Attestation Form ,comes to notice at any time
during the service of a person, his services would be
liable to be terminated.

Affix signed passport

size (5 cm x 7 cm copy of
recent photograph)

1.

2.

3.

Name in full (in block capitals

letters) with aliases, if any
(Place indicate if you have
added or dropped in any
stage any part of your name
of surname.
Present address in full (i.e.
Village, Thana and Distt. Or
House No., Lane / Street
Road and Town)
(a) Home address in full (i.e.
Vill., Thana and Distt. Or
House No., Lane / Street /
Road and Town have of
Distt. Hqr.
(b) If originally a resident of
Pakistan / Bangladesh
(erstwhile East Pakistan),
the address in that country
and the date of migration
to Indian Union.

4.
Particulars of places (with period of residence) where you have resided for more
than one year at a time during the preceding five years. In case of stay abroad (including
Pakistan), particulars of all places where you have resided for more than one year after
attaining the age of 21 years should be given.

From

To

5.

Residential address in
full (i.e. Village, Thana
& District or House No.
& Street / Road and
Town

Name (in full &

aliases, if any)

i)
ii)
iii)
iv)
v)

Nationality
(by Birth &
or by
domicile)

Place of
birth

Occupation
(if
employed
give
designation
& official
address.)

Name of the District

Hqtr., of the place
mentioned in the
preceding column

Present
postal
address (if
dead, give
last
Address)

Permanent
Home
Address

Father (Name in Full)

Mother
Wife/Husband
Brother(s)
Sister(s)

5. (a) Information to be furnished with regard to sons and / or daughters in case they are
studying / living in a foreign country.
Name Nationality
which (By Birth and
/ Or by Domicile)

Place of Birth

Country in which
studying / studying /
living with Full Address

6.

Nationality

7.

(a)
(b)

:
:

Date of Birth
Present Age

Date from which

Studying / Living in the
country mentioned in
the previous column

8.

(c)

Age at matriculation

(a)

Place of Birth, Distt., and :

State in which situated
Distt. And State to which :
You belonged
Distt. And State to which :
you Father originally belong

(b)
(c)

9.

(a)
(b)

Your religion
:
Are you a member of a SC/ST ? Answer
Yes or No
:

10.
Educational qualification showing place of education with years in schools and
colleges since 15th years of age.
Name of School/College
with Full Address

Date of
Entering

Date of leaving

Examination passed

11. (a) Are you holding or have any time

held an appointment under the Central
Govt. or State Govt. or a quasi-Govt. body
or an Autonomous body or a public
undertaking, or a private firm or
institution? If so, give full particulars with
dates of employment up to date
Period
Designation,
emoluments &
From
To
Nature of
employment

(b)

12.

Full name /
address of

Reasons for
leaving
previous
service

If the previous employment was under the Govt. of India / State Govt./an undertaking
owned or Controlled by the Govt. of India or a State Govt. an Autonomous Body /
University / Local Body, if you had left service on giving one months notice under
Rule 5 of the Central Service (temporary service) Rules 1965 or any similar
corresponding rules or where any disciplinary proceeding framed against you, or had
you been called upon to explain you conduct in any matter at the time you give notice
of termination of service or at a subsequent date (s) before your service.
(a)
(b)
(c)
(d)
(e)
(f)

Have you ever been arrested ?

Have you ever been prosecuted?
Have you ever been kept under detention?
Have you ever been bound down?
Have you ever been fined by a Court of Law?
Have you ever been convicted by a Court of law
for any offence ?

Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

(g)

Gave you ever been debarred from any

Examination or restricted by any University or
any other educational authority / institution ?

Yes/No

(h)

Have you ever been debarred / disqualified by

any Public Service Commission / Staff Selection
Commission for any of its examination / selection?

Yes/No

(i)

Is any case pending against you in any Court of

Law at the time of filling up this Attestation Form ?

Yes/No

(j)

Is any case pending against you in any University

or any other educational authority/institution at the

Yes/No

Yes/No

time of filling up this Attestation Form ?

(k)

Whether discharged / expelled / withdrawn

From any training / institution under the
Government or otherwise ?

(ii)

If the answer to any of the above mentioned question is Yes (give full
particulars of the case / arrest / detention / fine / conviction / punishment, etc.
and /or the nature of the case pending in the Court / University / Educational
Authority, etc. at the time of filling up this Attestation Form.

NOTE: i)
ii)

Yes/No

Please also see the Warning at the top of this Attestation Form.
Specific answers to each of the questions should be given by striking out
Yes or No as the case may be.

13.

Name of two responsible persons of your locality or two references to whom you
are known.

1.

2.

I certify that the foregoing information is correct and complete to the best of my
knowledge and belief. I am not aware of any circumstances which might impair my
fitness for employment under Government.

Signature of the Candidate

Place:
Date :

IDENTITY CERTIFICATE
(Certificate to be signed by any of the following)
i.

Gazetted Officer of Central Government or State Govt.

ii.

Members of Parliament or State Legislative belonging to the constituency

where the candidate or his parent / guardians ordinarily resident.

iii.

Sub-Divisional Magistrate /Officers.

iv.

Tehsildars or Naib Deputy Tehsildars authorized to exercise magisterial

power .

v.

Principal / Headmaster of the recognized School/College/Institution where

the candidate studied last.

vi.

Post Masters

vii.

Block Development Officer

viii.

Panchayat Inspectors.

Certified that I have known Shri / Smt./Kum._______________________

___________________________________

Son

Daughter

of

Shri__________

______________________for the last __________Years___________________ months

and that to the best of my knowledge and belief the particulars furnished by him / her are
correct.

Signature
Designation or Status & Address
Place:
Date :

i)

TO BE FILLED BY OFFICE
Name, Designation and Full Address of the appointment authority

ii)

Post for which the candidate is being considered.